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CPG 4 TO: OFi°'TCE OF REVENUE AND RECOVERY <br /> ACCOUNT fif2ANSMITTAL v4w1 Copy <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE T <br /> AKA - FIRST MI TITLE <br /> FIVE STAR <br /> TO DETAIL C/O NAME GUARANTO <br /> ALEX FLORES <br /> MAILING STREET CITV ST ZIP CODE AREA PHONE NO. <br /> 2560 S EL DORADO ST STOCKTON CA 95206 209-817-7396 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2531 S. LINCOLN ST. STOCKTON CA 95206 209-817-7396 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 14416 HAZMAT <br /> 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ------------ <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NA —230 042000.0 2012 Hazmat Fee $85.00 piq P44009.0j_ <br /> 30 014290010 1 Hazmat Penalty Fee $8.50 p8q o4 00 .0 <br /> p8q q429OOrO State Surcharge Fee $24.00 p8q P4300P.0 <br /> p8q 0I42goo,o Electronic Surcharge Fee $25.00 p8q P43009.01 <br /> 80 0I42Q00,0 p8q P44009.01 <br /> so 0I42qoolo I p8qa 00 .o <br /> ao o z oo. 8q P43009.0, <br /> TOTAL $142.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FIVE STAR AUTO DETAIL 209-817-7396 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2560 S EL DORADO ST STOCKTON CA 95206 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FIVE STAR AUTO DETAIL 209-817-7396 <br /> EMPLOYER STREET CITY ST 71P CODE <br /> 2560 S EL DORADO ST S OC T N CA 95206 <br /> PREPARED yC ECKED BY IDATE COL. 20(3188) <br />